Independent bilateral primary bronchial carcinomas

Transcription

1 Thorax (1971), 26, 476. Independent bilateral primary bronchial carcinomas M. RAY CHAUDHURI Department of Anatomic Pathology, Medical Faculty of Rotterdam, The Netherlands Independent bilateral primary bronchial carcinomas are not common. Since Beyreuther's description in 1924, 16 well-documented cases of independent primary bronchial carcinomas of different histology have been described. From 1965 to 1970, eight cases were seen at the London Chest Hospital. In order to make the diagnosis of a second primary bronchial carcinoma, each tumour should be malignant and neither should be a metastasis from the other. To meet this last criterion, the histopathological features of the two tumours must be different. Many cases have been described in the literature as double primary bronchial carcinomas where the second primary had the same histological features as the first. A patient with one primary cancer is more likely to develop another than would be expected from chance alone. Multiple carcinomas of paired organs, such as the breasts and ovaries, are not infrequent, and may be synchronous or nonsynchronous (Moertel, 1964; Mersheimer, Ringel, and Eisenberg, 1964; Fauvet, Chavy, and Piet, 1964). Since Billroth's initial report in 1914 multiple primary visceral carcinomas have been of perennial interest to pathologists. At present their general incidence ranges from 1 to 4 % of all cancer patients (Carvalho and Ferraro, 1966). In contrast, the development of two primary carcinomas in the lungs is an unusual phenomenon. In most published series of bronchial carcinomas, no mention at all is made of double primaries. Beyreuther (1924) was the first to describe such a case-a well-differentiated keratinizing squamouscell carcinoma in the right lung and an adenocarcinoma in the left. Since then 16 welldocumented cases of double primary bronchial carcinomas with different histological structures have been described (Table I). In making the diagnosis of two separate bronchial carcinomas, certain accepted criteria must be fulfilled. Warren and Gates (1932), Cahan, Butler, Watson, and Pool (1950), LeGal and Bauer (1961), Leafstedt, Sweetman, Chester, and Thorpe (1968), and Mobley and Martinez (1968) assert that, in order to make the diagnosis of a second primary bronchial carcinoma, each tumour should be separate from the other, each should be malignant, and neither should be a metastasis from the other. In order to meet this last criterion, the histopathological features of the two tumours must be entirely different. Many cases, including the case of Mobley and Martinez, have been described as examples of double primary bronchial carcinomas, although the second primary had a histological structure similar to the first. In these circumstances, TABLE I REPORTED CASES OF WELL-DOCUMENTED INDEPENDENT BILATERAL PRIMARY BRONCHLAL CARCINOMAS No. of Cases Year Reported Author Histopathology 1924 Beyreuther Squamous + adenocarcinoma 1932 Pirchan and gikl Squamous +oat-cell ca Chauvet and Feuardent Squamous +oat-cell ca Kainberger Squamous + oat-cell ca Fuchs Squamous+adenocarcinoma Robinson and Jackson Squamous +adenocarcinoma 1958 Newman and Adkins Squamous+adeno+oat-cell+alveolar-cell ca Azzopardi Squamous+oat-cell ca Mandel and Thomas Squamous +adenocarcinoma Onuigbo Squamous + adenocarcinoma Watson et al. Squamous+oat-cel ca Shields et al. Squamous+alveolar-cell ca Cliffton et al. Squamous+adenocarcinoma Castleman Squamous + oat-cell + alveolar-cell ca Leafstedt et al. Squamous+adenocarcinoma 476

2 *. *,. Independent bilateral primary bronchial carcinomas 477 the possibility of a metastasis rather than a second tumours was completely different and to present a primary is very strong and can never be ruled out further eight cases seen at the London Chest Hospital between 1965 and 1970 (Table II). These (Struve-Christensen, 1966). The purpose of this paper is to tabulate those eight cases were seen out of a total of 632 cases cases of independent bilateral primary bronchial of bronchial carcinoma, of which 413 were surgical carcinomas in which the histology of the two specimens and 219 were taken at necropsy. TABLE II PRESENT CASES OF INDEPENDENT BILATERAL PRIMARY BRONCHIAL CARCINOMAS First Primary Second Primary Case Year Site Histology Year Site Histology J.L R.U.L. Squamous-cell ca L.H. and Oat-cell ca. L.L.L. J.E.W L.U.L. Squamous-cell ca R.H. Oat-cell ca. H.A L.H. Squamous-cell ca R.L.L. Poorly-differentiated adenocarcinoma J.G R.L.L. Squamous-cell ca L.L.L. Oat-cell ca. J.C L.H. Adenocarcinoma-well R.L.L. Undifferentiated carcinoma of large polygonal differentiated, mucus-secreting cell type J.M L.H. Squamous-cell ca R.U.L. Poorly-differentiated adenocarcinoma W.M R.M.L. Squamous-cell ca L.U.L. Oat-cell ca. R.C L.L.L. Squamous-cell ca R.U.L. Oat-cell ca. R.U.L. =right upper lobe; L.U.L.=left upper lobe; R.M.L. =right middle lobe; R.H. =right hilum; L.H. =left hilum; R.L.L. =right lower lobe; L.L.L. =left lower lobe Am~~ * Tz v'v7 a W,,a U. r~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ ;V_i;t'rX9 FIG. 1. Growth in the right upper lobe. Histologically it is a well-differentiated keratinizing squamous-cell carcinoma. Haematoxylin and eosin x 235. (see text).

3 ~~~~~~~~~~~~~~~~ 478 M. Ray Chaudhuri ILLUSTRATIVE CASE liver, and the suprarenals as well as the hilar and mediastinal lymph nodes were infiltrated. J.L., a 60-year-old goods checker, who had smoked Histologically, the right upper lobe growth was a 40 cigarettes a day for over 40 years, was admitted well-differentiated keratinizing squamous-cell carcinoma with metastases in both the cerebral and cere- in May 1967 for investigation and treatment of a right upper lobe shadow. He had a long history of bellar cortices (Fig. 1). The hilar and peripheral chronic bronchitis, cough productive of yellow growths of the left lung, and the metastases in the sputum, and haemoptysis once in the last eight years. lymph nodes and both suprarenals, showed oat-cell Clinically no abnormality was detected. Bronchoscopy carcinoma with typical pseudorosette pattern (Fig. 2). was normal and neoplastic cells were not found in the Both types of growth were present side by side in sputum. In view of his poor respiratory function, the liver (Fig. 3). surgical intervention was not indicated and the patient was kept under constant supervision. He was finally admitted in September 1969 with DISCUSSION severe dyspnoea and diminished movement and dullness over the whole right upper lobe and the left upper lobe When a patient has two histologically distinct anteriorly. His condition deteriorated so quickly that primary bronchial carcinomas, one on each side, a repeat bronchoscopy was not possible. to prove that each is separate and independent is At necropsy, a large fungating tumour, 6 x 5 x 3 cm, was found at the apex of the right upper lobe. The often difficult. It is known that any bronchial tumour extended laterally into the chest wall, which carcinoma may present widely different histological features in different areas (Kreyberg, 1962; was densely infiltrated. The left lung contained a large hilar growth, 5x4x4 cm, with an extension, Willis, 1967; Ashley and Davis, 1967). In a 3 x 2 x 2 cm, in the anterior basal segment of the lower necropsy study.of 255 patients who died of lobe. The left cerebral and cerebellar cortices, the primary bronchial carcinoma, Auerbach, Stout,.. 'p. a s.*4*t. v *1 X4AS W - e ^ s*.41 vv 4, w.4 FIG. 2. Growth in the left hilum. Histologically it has the features ofan oat-cell carcinoma. H. and E. x 145. (see text).

4 Independent bilateral primary bronchial carcinomas 479 FIG. 3. Metastases in the liver, showing characteristic squamous-cell and oat-cell carcinoma side by side. H. and E. x 240. (see text). Hammond, and Garfinkel (1967) found nine cases of multiple invasive growths of different histological patterns, an incidence of 3f5%. In the present series, this amounts to only 1 2%. Leafstedt et al. (1968) argued that the respiratory epithelium tends to become metaplastic because it is in a dynamic state of constant renewal and is exposed to numerous irritants. Carcinogenesis is not an isolated biological accident, but probably the result of continued exposure to cigarette smoking, atmospheric pollution, and other irritants, which finally initiates irreversible malignant changes in the epithelium. It is hardly surprising that the process may continue in the same or opposite lung or in the residual bronchi left after resection of a bronchial carcinoma. An interesting feature of these independent bilateral primary bronchial carcinomas is that most of them were squamous in character in the first primary and incidentally became either poorly differentiated adenocarcinoma or oat-cell carcinoma or undifferentiated carcinoma of large 2M polygonal cell type. In the present series, five out of these eight cases showed oat-cell pattern in the second primary: of the remaining three, two were poorly differentiated adenocarcinomas and the other was an undifferentiated carcinoma of large polygonal cell type. The case illustrated confirms the histological differentiation by showing separate types of growth side by side in the metastases, particularly in the liver. In no other examples cited previously has this unique character of independent bilateral primary bronchial carcinomas been depicted. The most plausible explanation is the divergent differentiation of the original multipotent cancer cell, which can express itself in metastases in different organs. I am indebted to Dr. K. F. W. Hinson, Director of Pathology, Brompton Hospital, and Mr. J. R. Belcher, Consultant Surgeon, the London Chest Hospital, for their advice and criticism. I thank the physicians and surgeons of the London Chest Hospital for allowing me to report their patients; Mr. K. G. Moreman, Chester Beatty Institute, for the photographs; and

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